Provider Demographics
NPI:1497450043
Name:DYKSTRA, OLIVIA
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6321 INDUCON DR E
Mailing Address - Street 2:
Mailing Address - City:SANBORN
Mailing Address - State:NY
Mailing Address - Zip Code:14132-9016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6321 INDUCON DR E
Practice Address - Street 2:
Practice Address - City:SANBORN
Practice Address - State:NY
Practice Address - Zip Code:14132-9016
Practice Address - Country:US
Practice Address - Phone:716-650-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach